Provider Demographics
NPI:1073735775
Name:SMITH, COREY RYAN (ATC, PTA, CSCS)
Entity Type:Individual
Prefix:MR
First Name:COREY
Middle Name:RYAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:ATC, PTA, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:GLASCO
Mailing Address - State:NY
Mailing Address - Zip Code:12432-0509
Mailing Address - Country:US
Mailing Address - Phone:845-246-1418
Mailing Address - Fax:
Practice Address - Street 1:71 PROSPECT AVE
Practice Address - Street 2:COLUMBIA MEMORIAL HOSPITAL
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-2907
Practice Address - Country:US
Practice Address - Phone:518-828-8206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY67 001019174400000X
NY66 006329225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered174400000XOther Service ProvidersSpecialist
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant